EMGuidewire's Podcast

Join the crew from EMGuidewire as they are joined, once again, by Drs. Diurba and Folk for their unique perspectives from an intern's point of view. This month's Intern Nugget will cover sign-out and transition of care tips as well as some learning point on pediatric dehydration management and BRUE.

Join the EMGuideWire Team as they welcome back Dr. Chelsea Rushnell, prior Chief Resident at CMC Emergency Residency, to discuss the management of the anticoagulated trauma patient. Perhaps just flooding individuals with FFP is not the best strategy. Dr. Rushnell will review the evidence for the use of 4 Factor PCC.

Join the EMGuideWire team from CMC EM residency as they hear a fresh perspective... from newly minted residency Interns, Drs. Destiny Folk and Sofiya Diurba.

For this Intern Nugget, they address:

1) Imposter Syndrome and how to overcome it.

2) Complex Regional Pain Syndrome and how to manage it.

3) Analgesia options in the ED

Join the EMGuidewire team at Carolinas Medical Center Emergency Medicine program as they discuss important topics. This week, Drs. Cravens and Kastner discuss Penetrating Cardiac Injury (PCI):

-The diagnosis of PCI is made in the trauma bay with repeat cardiac ultrasound exams and chest x-ray. If suspicion remains high despite inconclusive imaging, operative subxiphoid pericardial window is the definitive diagnostic modality.

-Large pericardial injury, especially from ballistic injuries, can result in PCI without positive pericardial fluid on FAST, if the blood is draining into the hemithorax. This would result in hemothorax, but not always with high enough drainage to mandate operative intervention if PCI is not kept with high index of suspicion.

-ED management of PCI is stabilization until the patient can be managed in the OR with sternotomy and external cardiac repair. In the pulseless patient with recent arrest, ED thoracotomy is indicated, provided operating room intervention is available immediately following. Unstable patients with a pulse need immediate operative intervention; if FAST is positive for pericardial fluid, ED pericardiocentesis should be considered as a temporizing measure in these patients, especially if transfer is needed for OR intervention.

Join the EMGuideWire Team from CMC EM group as they explore the initial thoughts and management of a patient who presents with severe Diabetic Ketoacidosis (DKA). For this episode, Drs. Claire Milam and Travis Barlock explore the initial considerations and practical management tips.

Definitions of severity of DKA:

Mild

• • pH: 7.25-7.3
  • CO2: 15-18 mEq/L
  • Anion Gap: > 10 mEq/L
  • Mental Status: Alert
  • Blood Glucose: >250 mg/dl
  • Urine and Serum Ketones: Positive

Moderate

• • pH: 7.0-7.24
  • CO2: 10-15 mEq/L
  • Anion Gap: >12 mEq/L
  • Mental Status: Alert to Drowsy
  • Blood Glucose: >250 mg/dl
  • Urine and Serum Ketones: Positive

Severe

• • pH:
  • CO2:
  • Anion Gap: > 12 mEq/L
  • Mental Status: Stuporous to Comatose
  • Blood Glucose: >250 mg/dl
  • Urine and Serum Ketones: Positive

Join the Drs. Ray and Barlock from the EMGuideWire team as the discuss the initial assessment and evaluation of some ocular complaints with specific attention to pathology of the Posterior Eye.

SHOWNOTES:

Key PointsAlways get visual acuity for any eye complaint Swinging flashlight test can help with your diagnosis Dilate the eyes for optimal fundoscopic exam Optic neuritis -> give IV steroids Use U/S to look for papilledema along with optic nerve sheath diameter Find the optic nerve when evaluating retinal detachment vs vitreous hemorrhage CRAO= "stroke of the eye" CRVO= "DVT of the eye"

Optic NeuritisOnset: Acute Pain: With EOMI, can be painless Visual Acuity: Decreased Laterality: Usually unilateral, can be bilateral Classic presentation: Young female (15-45) with acute vision loss Exam: + APD Associations: MS, infection (lyme, herpes, syphilis), autoimmune, methanol, DM Treatment: IV steroids

Papilledema Onset: Subacute to chronic Pain: Headache Visual Acuity: Normal initially Laterality: Bilateral Classic presentation: Headache, N/V, transient vision loss Exam: Optic disc swelling Treatment: treat underlying cause

Retinal Detachment Onset: Sudden Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden, painless, with flashes, or a curtain over the visual field Exam: +/- mild APD Management: Ophtho consult, minimize activity, treat underlying cause, surgical options available

Central Retinal Artery OcclusionOnset: Sudden Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden, painless vision loss in vasculopathy Exam: + APD Associations: carotid vascular disease, pediatric blood disorders (SCD, leukemia) Management: Ophtho consult, restore blood flow

Central Retinal Vein OcclusionOnset: Acute Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden blurry or distorted vision in hypercoagulable patient Exam: + APD Associations: OCPs, HTN, DM, vasculitis Management: Ophtho consult

Join the EMGuidewire team as Drs. Serven and Blackwell discuss the management of the patient presenting with Severe Status Asthmaticus in the Emergency Department. Don't forget to review the basic concepts that were published earlier... this time the focus is on the critically ill patient.

Join the EMGuidewire Team as they address how to prepare for the arrival of a trauma patient in your Emergency Department. Drs. Serven and Blackwell from Carolinas Medical Center Emergency Medicine Residency Program will give us some insight and pearls on how to manage the potential chaos.

Join the EMGuideWire team as Drs. Serven and Shreve are joined by Dr. Trigonis to discuss simple strategies to make sure your room is set up and you are prepared for performing an emergent intubation on your patients in the Emergency Department.

Shownotes - Once through start to finish:

• Set up suction
• Set up pre-oxygenation (nasal cannula, NRB, BVM as backup)
• Choose a tube + back up tube
• Lube the tube, check the tube
• Choose a stylet
• Set up video and DL
• Ask nurse for meds (nicely)
• Check hemodynamics
• Acknowledge preoxygenation
• Positioning
• Give meds
• Wait for paralytic medications to work
• Tube 'em
• Call out your tube positioning
• Leave the blade in place until tube placement assured
• Confirm with color change, EtO2, bilateral breath sounds
• Wait for RT to secure the tube
• Call for post-intubation meds
• Check CXR for position

Join Drs. Alyssa Thomas and Victoria Serven from Carolinas Medical Center Emergency Medicine Residency Program and the EMGuideWire Team as they discuss how they initially evaluate and manage the patient who present with acute pulmonary edema and hypertension.